RETROPHARYNGEAL ABSCESS

Question 1

Approach to the Critically Ill Retropharyngeal Abscess

Answer 1

Monitor
Oxygen
Vitals
IV Access
Equipment: Airway

AIRWAY
Rapid Bedside Assessment:
Drooling
Voice change
Stridor
Inability to speak
Tripod or sniffing positioning
Hypoxia
Swelling of the posterior oropharynx
Inability or unwillingness to lie flat

Position upright, head tilt / chin lift

Secure Airway in patients with impending airway obstruction

Awake / Nasal Intubation if Limited oral access

Fiberoptic Visualization > Video Laryngoscopy > Direct

Prepare for surgical airway PRIOR to non-surgical airway

Dexamethasone 0.6 mg/kg (max 10 mg)
OR
Methylprednisone 125 mg

Serial Airway Assessment

Urgent ENT Consult for further visualization/urgent nasopharyngeal scope/laryngoscopy in stable patients

CIRCULATION
Bolus 20 ml / kg Crystalloid if needed

Broad spectrum antibiotics coverage for Staph, Strep, Anaerobes:

Ampicillin-sulbactam 50 mg/kg IV every 6 hours (maximum dose 3,000 mg)
OR
Clindamycin 15 mg/kg IV every 8 hours (maximum dose 900 mg)
Penicillin Allergy:
Ceftriaxone 50 mg / kg / dose IV

Piperacillin-tazobactam (dose by age):
Age 2 months to 9 months: 80 mg/kg/dose (based on piperacillin component) intravenous every 8 hours (maximum dose 3,000 mg piperacillin)
Age >9 months, children, and adolescents weighing <40 kg: 100 mg/kg/dose (based on piperacillin component) intravenous every 6 hours (maximum dose 4,000 mg piperacillin)
Children and adolescents weighing >40 kg: 4,500 mg piperacillin intravenous every 6 hours

Question 2

History & Physical

Answer 2

Recent URTI
Recent Trauma (foreign body)

Fever
Decreased oral intake
Odynophagia (refusal to eat)

Neck Tenderness or Swelling
Nuchal Rigidity / Painful Neck ROM

Drooling
Stridor
Cervial LAD
Torticolis

Question 3

DDx

Answer 3

Angioedema
Bacterial Tracheitis
Diphtheria
Epiglottitis
Lemierre Syndrome
Ludwig Angina
Mononucleiosis
Peritonsillar Abscess
Retropharyngeal Abscess
Uvulitis

Question 4

Investigations

Answer 4

Upright Lateral Neck XRAY

Obtained during inspiration with the neck in extension

CT Neck with IV contrast if the patient is able to lie flat - preferred modality

Question 5

XRAY Features: Retropharyngeal Abscess

Answer 5

prevertebral space (the distance between the anterior border of the vertebral body and the air within the pharynx/trachea

a retropharyngeal space wider than 7 mm at C2 OR
wider than 14 mm (children) C6 is abnormal

Question 6

Disposition

Answer 6

Admission